The candidate is a community/public health nurse and gerontological health services researcher committed to comparative effectiveness research on home health delivery systems. Her short-term training objectives are (1) to develop comparative effectiveness research methods expertise and (2) data management and analytic methods specific to home health care datasets and research design issues. Long term research goals are to improve the design and deliver of home health nursing care outcomes for a rapidly aging and increasingly diverse population. In addition to focused research, career development plans include interaction with colleagues on her mentoring/research team, formal course work will be taken in comparative effectiveness research methods. The University of Pennsylvania will provide an outstanding environment for her career development. Resources include access to eminent interdisciplinary faculty who collaborate through focused Research Centers in Health Services Research, Aging and Comparative Effectiveness Research, across the Schools of Nursing, Medicine, Sociology, Statistics, and Business. Guided by excellent mentors, in a superb training environment, with access to rich datasets and strong preliminary data, this proposal addresses three specific aims: 1) Compare the effectiveness of nursing delivery system strategies (more nurses educated at the baccalaureate level, front-loading of nursing visits, and supportive agency work environments) to improve home health patient outcomes~ 2) Determine if and under what conditions the impact of nursing on home health outcomes is contingent upon informal caregiver assistance~ and 3) Determine the extent of racial/ethnic disparities in home health outcomes, and determine which nursing system delivery strategies are most likely to be associated with improved outcomes for racial/ethnic minority patients and clinically complex older adults. The proposed training and research will utilize the latest advances in comparative effectiveness research methods to detect racial/ethnic disparities in home health outcomes, understand the contributing factors (individual, family, community and health systems), and evaluate the comparative effectiveness of nursing delivery system strategies on improving outcomes for home health patients under different individual and socio-environmental circumstances. This innovative project will capitalize on a unique data set, comprised of nurse surveys providing detailed information about nursing care and work environment within home health agencies in nearly 250 home health agencies that serve older adults living in diverse communities. The nurse survey results combined with independent home health care patient assessment and outcomes data provides a window into each patient's unique circumstances, including the complexity and severity of their health status and care needs, as well as information about their living environment and informal caregivers. Linkages with additional administrative and public datasets will provide additional key variables regarding home health agency service patterns and community measures of crime, segregation, socio-economic status and health care provider availability/shortages. The proposed research is significant because it will highlight the value of different home health nursing delivery strategie for improving patient outcomes among vulnerable populations may be achieved. The challenge being addressed--how to best provide safe, effective, and affordable home health nursing care to diverse patients--affects patient outcomes across the continuum of care from home to medical home and hospital. Limited evidence is available to guide home health care systems administrators in making decisions about the pros and cons of home health nursing delivery system strategies. The best combination of home health nursing care delivery strategies may be categorically different depending on the presence of informal family caregivers and community supports. Professional home health nursing care and informal (lay) or community care may interact synergistically to increase the effectiveness of systems level intervention, for example, by reducing the intensity of services needed. The comparative effectiveness study proposed will form a critical body of evidence needed to translate effective nursing delivery system strategies into evidence-based practice recommendations that providers, payers, purchasers, policy makers, other principle investigators, and the public can trust.